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TENNESSEE’S WORKERS’ COMPENSATION

MEDICAL FEE SCHEDULE

Introduction and Overview

The Tennessee Workers’ Compensation Medical Fee Schedule Rules became effective

July 1, 2005, pursuant to a mandate from the Tennessee General Assembly as part of the

Tennessee Workers’ Compensation Reform Act of 2004. See Tenn. Code Ann. § 50-6-

204(i). The Medical Fee Schedule has undergone several revisions since the first version

became effective on July 1, 2005. The current version of the MFS, permanent

rulemaking hearing rules, became effective on August 26, 2009. The version effective at

the time a medical service is or was rendered is the applicable one for that service.

Our Medical Fee Schedule is made-up of three (3) parts, called chapters, of

administrative rules. These three (3) chapters are: Chapter 0800-2-17, 0800-2-18 and

0800-2-19. The first chapter, 0800-2-17, is called the Medical Cost Containment

Program Rules. This part contains general information applicable to the other two

chapters. It contains most of the definitions used throughout all three chapters, as well as

the purpose, scope, general guidelines and procedures. This part explains such things as

the basis for the Medical Fee Schedule (Medicare for most of the Medical Fee Schedule),

the time-period payers have to timely reimburse providers for undisputed bills, what

happens if payers do not comply, and appeal procedures, etc.

The second chapter, Chapter 0800-2-18, is the actual Medical Fee Schedule Rules and

addresses such things as the proper conversion factors to use for calculating the

maximum allowable amounts for physicians’ professional services, depending on the

type of service they provide (determined by the classification of the CPT codes), the

maximum allowable amounts that may be paid for certain types of medical devices and

equipment, such as durable medical equipment and prosthetics and orthotics, penalties for

violations of the Medical Fee Schedule, what actually constitutes a violation, etc.

Chapter 0800-2-19, the In-patient Hospital Fee Schedule, sets out how hospitals should

be reimbursed. Unlike most of our Medical Fee Schedule, this section, for the most part,

is not based on Medicare methods, but reimburses hospitals on a per day or “per diem”

basis. This section also contains definitions and procedures specifically applicable to

inpatient hospital reimbursements.

These three (3) chapters of administrative rules listed above are referred to collectively as

the Tennessee Workers’ Compensation Medical Fee Schedule, the Medical Fee Schedule,

the Fee Schedule, or MFS.

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Table of Contents

I. Definitions and References. ....................................................................................... 4

II. General Information. ................................................................................................. 6

A. Applicability of the Tennessee Workers’ Compensation Medical Fee Schedule

……………………………………………………………………………….7

B. The Tennessee Medical Fee Schedule is a “Cap”……………………………..7

C. Clarification Regarding the Medicare “Floor” for Maximum

Allowable Reimbursements under the Medical Fee Schedule .......................... 7

D. Depositions ............................................................................................................ 8

E. Usual and Customary ....................................................................................... 8

F. Out-of-State Medical Services .......................................................................... 8

G. Adjustments to Bills ......................................................................................... 8

H. Charges for Medical Reports ............................................................................ 9

I. Impairment Ratings and Evaluations ................................................................ 9

J. Missed Appointments ..................................................................................... 10

K. Payment. .............................................................................................................. 10

L. Utilization Review .......................................................................................... 11

M. Penalties for Violations .................................................................................. 11

N. Miscellaneous ...................................................................................................... 11

O. Administrative Appeals and Disputes Regarding Reimbursement ................. 12

III. Tennessee Medical Fee Schedule: Medical Services. .............................................. 13

A. Anesthesia Services ........................................................................................ 13

B. Injections ............................................................................................................. 13

C. Home Healthcare ............................................................................................ 14

D. Skilled Nursing Facility Charges .................................................................... 14

E. Outpatient Services (Including Emergency Room Care if Patient is not

Admitted .............................................................................................................. 14

F. Pathology Services ......................................................................................... 15

G. Radiology Services ......................................................................................... 15

H. Chiropractic Services ..................................................................................... 15

I. Physical Therapy/Occupational Therapy (PT/OT) ......................................... 16

J. Speech Therapy .............................................................................................. 16

K. Durable Medical Equipment and Implant Reimbursement ............................. 16

L. Medical Supplies. ........................................................................................... 17

M. Orthotics and Prosthetics ................................................................................ 17

N. Pharmacy. ............................................................................................................ 17

O. Ambulance Services. ...................................................................................... 18

P. Clinical Psychological Services ...................................................................... 18

Q. Surgery, Surgical Assistants and Modifiers .................................................... 18

R. Professional Services ...................................................................................... 20

S. Dentistry .............................................................................................................. 22

T. Physician’s Assistants and Certified Nurse Practitioners-Maximum

Reimbursement .................................................................................................... 22

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IV. In-Patient Hospital Fee Schedule ............................................................................ 24

A. In-Patient Hospital Services are Reimbursed under a Per Day

Methodology .................................................................................................. 24

B. Maximum Allowable Reimbursement Amounts ............................................ 24

C. Trauma Care ................................................................................................... 25

D. Surgical Implants ........................................................................................... 25

E. Non-covered Charges. .................................................................................... 25

F. Amounts in Addition to Per Diem Charges ................................................... 25

G. Reimbursement Calculations Explanation: .................................................... 26

H. Stop-Loss Method .......................................................................................... 27

I. Pre-admission Utilization Review .................................................................. 28

J. Pharmacy Services ......................................................................................... 28

K. In-Patient Hospital Fee Schedule Definitions ................................................ 28

L. Penalties for Violations of the In-Patient Hospital Fee Schedule ................... 28

M. Additional Information about the Medical Fee Schedule. .............................. 28

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I. DEFINITIONS AND REFERENCES

Most definitions needed for proper use of the Tennessee Medical Fee Schedule are

provided in the Medical Cost Containment Program Rules, specifically Rule 0800-2-17-

.03. These should be consulted thoroughly to familiarize you with the particular

meanings of terms used throughout the Medical Fee Schedule and in the Inpatient

Hospital Fee Schedule. The definitions and references below are provided as an

additional aid in use of the Fee Schedules.

CPT CODE

The Current Procedural Terminology (“CPT”) code is obtained from the current edition

of the American Medical Association’s Current Procedural Terminology. Further

information regarding CPT codes is available at the Centers for Medicare and Medicaid

Services website at http://www.cms.hhs.gov/ . These codes are available for purchase at

various sites on the internet including http://www.ama-assn.org/ .

DIAGNOSIS CODE

Diagnosis code is the "ICD 9" code which best describes the reason(s) for the procedure,

service, supply or encounter. Further information regarding ICD-9 codes is available at

the Centers for Medicare and Medicaid Services website at http://www.cms.hhs.gov/ .

These codes are available for purchase at various sites on the internet including

http://www.ama-assn.org/ .

ICD9 PROCEDURE CODE

“ICD 9” means the current edition of the International Classification of Diseases,

published by the World Health Organization's (WHO). Further information regarding

ICD-9 codes is available at the Centers for Medicare and Medicaid Services website at

http://www.cms.hhs.gov/ . These codes are available for purchase at various sites on the

internet including http://www.ama-assn.org/ .

HCPCS CODE

Services and medical supplies must be coded with valid procedure or supply codes of the

Health Care Financing Administration Common Procedure Coding System (“HCPCS”).

Further information regarding HCPCS is available at the Centers for Medicare and

Medicaid Services website at http://www.cms.hhs.gov/ . The codes are available for

purchase at various sites on the internet including http://www.ama-assn.org/ .

NDC CODE

National Drug Code – information is available at the following website.

http://www.fda.gov/cder/ndc/index.htm .

CMS means the U.S. Centers for Medicare and Medicaid Services.

U & C means the usual and customary amount, which is 80% of billed charges.

BR (By Report) means the procedure is not assigned a maximum fee and requires a

written description. Paid at U & C (80% of billed charges).

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CPT means the current edition of the American Medical Association’s Current

Procedural Terminology.

Independent Medical Examination (“IME”) refers to an examination and evaluation

conducted by a practitioner different from the practitioner providing care, other than one

conducted under the Division’s Medical Impairment Rating Registry Program (MIRR).

An IME shall be billed at $500.00 per hour and pro-rated per quarter hour. Physicians

may only require a pre-payment of $500.00 for an IME. Following completion of the

IME and report, the physician may bill for other amounts appropriately due. The office

visit billed is included with the code and shall not be billed separately. Lab, x-rays, or

other tests shall be identified and reimbursed accordingly.

Physicians who perform consultant services and/or records review in order to determine

whether to accept a new patient shall not bill for an IME. Rather such physicians shall

bill using CPT codes 99358 for the first hour and 99359 for each additional quarter hour.

The reimbursement shall be $200.00 for the first hour of review and $100.00 for each

additional hour; provided that each quarter hour shall be pro-rated.

Pattern of Practice means at least one or more violations of the Medical Fee Schedule

Rules, the Medical Cost Containment Rules and/or the In-patient Hospital Fee Schedule

Rules have occurred after the notice of a violation has been issued from the Department

for the first violation.

Preauthorization means the employer or carrier accepts the injured or disabled

employee’s injury or disease as compensable under the Act and authorizes payment of

benefits under the Act. Preauthorization is required for all non-emergency medical

services (outpatient and inpatient). Failure to timely communicate (within seven (7)

working days) the decision of authorizing or not authorizing the service requested by a

medical provider shall result in the authorization being deemed appropriate.

Primary Procedure means the therapeutic procedure most closely related to the

principle diagnosis.

Utilization Review means the evaluation of the necessity, appropriateness, efficiency,

and equality of medical care standards provided to an injured or disabled employee based

on medically accepted standards and an objective evaluation of the medical care services

provided; provided that “utilization review” does not include the establishment of

approved payment levels or a review of medical bills or fees.

Utilization review providers must be certified by the Tennessee Department of

Commerce and Insurance.

All of the above definitions, as well as many others, may be found in Rule 0800-2-17-.03

and should be consulted.

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II. GENERAL INFORMATION

Unlike fee schedules in some other states, Tennessee’s Medical Fee Schedule does not set

an absolute fee for services, but instead, sets a maximum amount that may be paid.

Providers and payers are encouraged to negotiate amounts below the maximum set in the

Medical Fee Schedule, but shall not pay an amount above the Fee Schedule maximum

amount. A payer paying in excess of the Fee Schedules and a provider retaining

excessive reimbursement over 90 days is a violation of the Fee Schedule Rules and may

result in penalties up to a $10,000.00 civil penalty against both payer and provider,

among other measures, based on the Commissioner’s (or the Commissioner’s

Designee’s) discretion. See Rule 0800-2-18-.02(2)(b)(4.)

The Medical Fee Schedule applies to all medical services and medical equipment or

supplies. Reimbursement to all providers shall be the lesser of: (1) the provider’s usual

charge, (2) the maximum fee schedule under these Rules, or (3) the MCO/PPO or any

other negotiated and contracted amount. See Rule 0800-2-18-.02(b). This lesser of

comparison must be done on the total bill or amount due, NOT a line-by-line

comparison of items.

When there is no specific methodology in these Rules for reimbursement, the maximum

reimbursement is 100% of Medicare. Whenever there is not Medicare methodology,

maximum reimbursement is Usual & Customary or U & C (80% of billed charges). See

Rule 0800-2-18-.02(a).

Procedure codes for unlisted procedures should only be used when there is no procedure

code which accurately describes the services rendered. These codes require a written

report and are paid at a maximum allowable amount of usual and customary (80% of

billed charges.) See Rule 0800-2-17-.06.

Unless otherwise stated in the Rules, the current effective Medicare procedures and

guidelines are to be used. See Rule 0800-2-18-.02(a).

Relative Value Units (“RVUs”) may be obtained from the current edition of the Medicare

RBRVS: The Physician’s Guide. This should be used in conjunction with the current

edition of the AMA’s CPT Coding Guide. These books may be obtained by contacting

the American Medical Association at American Medical Association, 515 N. State

Street Chicago, IL 60610, telephone (800) 621-8335, or by visiting the AMA’s bookstore

online at the American Medical Association’s website: www.ama-assn.org .

When extraordinary services resulting from severe head injuries, major burns, severe

neurological injuries, or any injury requiring an extended period of intensive care, a

greater fee may be allowed up to 150% of the professional service fees normally allowed

under these Rules. This provision does not apply to In-patient Hospital facility fees. See

Rule 0800-2-1.

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A. Applicability of the Tennessee Workers’ Compensation Medical Fee

The Medical Fee Schedule is applicable to all injured employees, no matter where the

injury took place, so long as that person is claiming workers’ compensation benefits

under Tennessee’s workers’ compensation law. It is applicable to all medical services for

these injured employees based on the date the medical service is received, not on the date

of the employee’s injury.

See Rule 0800-2-17-.01.

B. The Tennessee Medical Fee Schedule is a “Cap”

Tennessee’s Workers’ Compensation Medical Fee Schedule sets out a “lesser of”

comparison for reimbursement. Employers, carriers, and providers may negotiate and

contract fees as are agreeable between them, but reimbursement must be in accordance

with the Rules. It is a violation of the Medical Fee Schedule for a provider to receive and

retain, and for a payer to remit an amount above the Fee Schedule amount. Both the

payer and the provider may be liable for a civil penalty of up to $10,000.00 each if a

“pattern or practice” of payments in excess of the Medical Fee Schedule is found. The

term “pattern or practice” is defined in Rule 0800-2-17-.03(61) of the definitions section

in the Medical Cost Containment Program Rules and at the end of this section. Other

violations of the Rules shall subject the violator to a penalty of not less than $100 nor

more than $10,000 per violation.

See Rule 0800-2-17-.01.

C. Clarification Regarding the Medicare Maximum Allowable Reimbursements

Unless otherwise indicated, the current, effective Medicare procedures and guidelines are

adopted and effective upon adoption and implementation by the CMS. Whenever there is

no specific fee or methodology for reimbursement in the Medical Fee Schedule Rules for

a service, diagnostic procedure, equipment, etc., then the maximum amount of

reimbursement shall be 100% of the current effective CMS’ Medicare allowable amount;

provided that any practitioner fee shall be based on the conversion factor of 33.9764,

which shall be used in conjunction with the most current Medicare RVU’s. The current

effective Medicare guidelines and procedures shall be followed in arriving at the correct

amount. Whenever there is no applicable Medicare code or method of reimbursement,

the service, equipment, diagnostic procedure, etc. shall be reimbursed at the usual and

customary amount as defined in the Medical Cost containment Program Rules at 0800-2-

17-.03(80).

See Rule 0800-2-18-.02(2)(a).

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D. Depositions

Procedure code 99075 must be used when billing for a deposition. The rate of maximum

reimbursement for depositions is established in Division Rule 0800-2-16-.01. Licensed

physicians may charge their usual and customary fee for providing testimony by

deposition to be used in a workers’ compensation claim, provided that such fee does not

exceed seven hundred fifty dollars ($750) for the first hour’s time. Depositions requiring

over one (1) hour in duration shall be pro-rated at the licensed physician’s usual and

customary fee as set forth above, not to exceed four hundred fifty dollars ($450) per hour

for deposition time in excess of one (1) hour. Physicians shall not charge for the first

quarter hour of preparation time. In instances requiring over one quarter hour of

preparation time, a physician’s preparation time in excess of one quarter hour shall be

added to and included in the deposition time and billed at the same rates as for the

deposition.

See Rule 0800-2-16-.01.

E. Usual and Customary under the Medical Fee Schedule

Many medical services under our Medical Fee Schedule are capped at the “usual and

customary” amount. This usual and customary amount is defined in Rule 0800-2-17-

.03(80). Quite simply, the usual and customary amount means 80% of the billed charges.

F. Out-of-State Medical Services

The Tennessee Medical Fee Schedule Rules apply whenever an injured employee is

receiving workers’ compensation benefits under Tennessee law or would be entitled to

receive benefits under Tennessee law, whether the treatment is in Tennessee or any other

state.

See Rule 0800-2-17-.01.

G. Adjustments to Bills

A carrier’s payment shall reflect any adjustments in the bill. A carrier must provide an

explanation of medical benefits to a health care provider whenever the carrier’s

reimbursement differs from the amount billed by the provider.

See Rule 0800-02-17-.10 (6)(a).

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H. Charges for Medical Reports

Consistent with the statute governing these transactions, a provider may charge up to

$10.00 for a medical report of twenty pages or less, and charge $0.25 per page for

additional pages, so long as it is a complete medical report; this cost shall also apply to

paper records transmitted on a disc or by other electronic means based upon the number

of pages reproduced on the disc or other media. However, submission of an office note is

NOT considered a medical report and no compensation may be charged for

submission of such documentation when needed for the payer to make determinations

concerning treatment plans and payments. Providers should not charge for progress

reports for follow up visits.

Charging for a medical report when simply providing progress reports (even if a copy of

a prior medical report is included) to a payer to make determinations concerning payment

and treatment plans is a violation of the Medical Fee Schedule and such violations will be

penalized. Providers may not charge for completing a medical report form required by

the Division.

If requested to do so, a provider must submit a complete C-32 Form within two (2)

weeks of such request. The physician may charge up to one hundred fifty dollars

($150.00) for completing this form. See Rule 0800-2-1-.16.

See Rules 0800-2-17-.15, 0800-2-17-.16 and 0800-2-1-.16.

I. Impairment Rating and Evaluations

The following is not applicable to Independent Medical Examinations (“IME”).

This applies to all workers’ compensation claims with initial dates of service on or

after January 8, 2009.

A treating physician who determines the employee’s maximum medical improvement

date for the distinct injury he/she is treating shall also determine the impairment rating.

A treating physician is defined in these rules as:

1. a physician chosen from the panel required by T.C.A. Section 50-6-204;

2. a physician referred to by the physician chosen from the panel required by T.C.A.

Section 50-6-204;

3. a physician recognized and authorized by the employer to treat an injured

employee for a work-related injury; or

4. a physician designated by the Division to treat an injured employee for a work-

related injury.

Within twenty-one (21) calendar days of the date the treating physician determines the

employee has reached maximum medical improvement, the treating physician shall

submit to the employer or carrier, as applicable, a fully completed report on a form

prescribed by the Commissioner. The employer or carrier, as applicable, shall submit a

fully completed form to the Division and the parties within thirty (30) calendar days of

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the date the treating physician determines the employee has reached maximum medical

improvement.

Upon determination of the employee's impairment rating, the treating physician shall enter

the employee's impairment rating into the employee's medical records. In a response

to a request for medical records pursuant to T.CA Section 50-6-204, a provider, treating

physician or hospital shall include the portion of the medical records that includes the

impairment rating.

The treating physician shall receive reimbursement of no more than $250.00.

For payment, the charge (CPT code 99455 and an explanation) must be submitted to the

appropriate insurance company, third party administrator or employer

See Rule 0800-2-17-.25

5. Missed Appointments

If an appointment is scheduled by the employer, carrier, or a case manager representing a

carrier or employer, a provider may charge up to the amount of the basic office visit

amount for a missed appointment. Missed appointments should be billed with the 99199

code, but an explanation of what would have been done with appropriate CPT codes

should accompany the bill. Whatever was authorized may be charged and paid at the

Medical Fee Schedule conversion factor amounts. This includes physical therapy; the

modalities up to four can be billed if they were approved and would have been rendered.

See Rule 0800-2-17-.14.

6. Payment

Carriers must provide an explanation of medical benefits to the health care provider

whenever the carrier’s reimbursement differs from the amount billed. A carrier must

date-stamp medical bills and reports upon receipt.

Any carrier that fails to pay an undisputed and properly submitted bill or the portion of

that bill which is undisputed within thirty-one (31) calendar days of receipt shall be

assessed a civil penalty of 2.08% monthly (25% annual percentage rate) which is paid to

the provider.

If a provider submits a bill on an improper form, the carrier has 20 calendar days of

receipt of the bill to return it. The days between the date the carrier returns the bill and

the date the carrier receives the corrected bill shall not apply towards the thirty-one

calendar days the carrier has to pay the bill.

Providers shall not attempt to collect the balance of a bill from the injured employee.

See Rule 0800-2-17-10.

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7. Utilization Review

Utilization review is required whenever there is a dispute as to the medical necessity of a

recommended treatment. Utilization review is required in the form of pre-admission

review for all inpatient admissions, and concurrent review should be done through

discharge. Emergency admissions require utilization review within one business day of

the admission.

Utilization review is required on chiropractic, physical and occupational services after

twelve visits. In order to facilitate expedited utilization review, whenever a physician

orders PT or OT the physician should include the diagnosis on the prescription for PT or

OT.

Utilization review is required for psychological treatment services in excess of fifteen

(15) visits.

See Rules 0800-2-17-.20, 0800-2-18-.09 and 0800-2-18-.14.

8. Penalties for Violations

Under the Medical Fee Schedule, civil penalties may be assessed by the Commissioner,

at his discretion, up to $10,000.00. Although the Fee Schedule became effective July 1,

2005, these penalty provisions did not become effective until January 1, 2006, and will

not be retroactive, that is, they are not applicable to violations pre-January 1, 2006.

See Rules 0800-2-17-.01(1), 0800-2-17-.13, 0800-2-18-.02(2)(b)4. & 5. and 0800-2-18-

.15.

9. Miscellaneous

The MFS is code specific in that the appropriate conversion factor to use is determined

by the type of CPT code for the procedure, such as surgery, radiology, evaluation and

management, etc. The AMA CPT guides should be used when determining if a code is

surgical or medical.

All physicians’ office visits are paid up to a maximum of 160% of the Tennessee

Medicare amount which should be calculated based on the conversion factor of 33.9764

rather than the current Medicare conversion factor, regardless of specialty. Physician’s

Assistants and Nurse Practitioners may be reimbursed up to a maximum of 100% of what

Medicare would have paid to them as Physician’s Assistants or Nurse Practitioners in

Tennessee which should be calculated based on the conversion factor of 33.9764 rather

than the current Medicare conversion factor.

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10. Administrative Appeals and Disputes Regarding Reimbursement

Whenever a disagreement exists between a payer and provider regarding a request for

either the recovery of payment or for the full payment, either party may send the issue to

the Medical Care and Cost Containment Committee for administrative review and a

recommendation. Also, disputes as to the application or interpretation of the Medical Fee

Schedule Rules may be submitted to the MCCCC for review.

If the request for review does not contain proper documentation including the required

C-47 form, then the MCCCC will decline to review the dispute. Likewise, if the

timeframes are not met, then the MCCCC will decline to review the dispute, but such

failure shall not provide an independent basis for denying payment or recovery of

payment.

All requests for administrative review by the MCCCC must be sent to: Medical Director

of the Division of Workers’ Compensation, Tennessee Department of Labor &

Workforce Development, 220 French Landing Dr., Nashville, Tennessee 37243.

See Rules 0800-2-17-.21 and -.22.

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III. TENNESSEE MEDICAL FEE SCHEDULE:

MEDICAL SERVICES

A. Anesthesia Services

Reimbursement for anesthesia services shall not exceed the maximum allowable of

$75.00 per unit. This is only applicable for anesthesia CPT codes, and does NOT include

pain management services reimbursed under surgical codes (maximum reimbursement up

to 200% of the Tennessee Medicare amount), or other injections, which are covered

below under the Injections section.

(a) When anesthesia is administered by a CRNA not under the medical direction of an

anesthesiologist, maximum reimbursement shall be 90% of the maximum allowable

fee for the anesthesiologist. No additional payment will be made to any physician

supervising the CRNA.

(b) Whenever anesthesia services are provided by an anesthesiologist or other

physician and a CRNA, reimbursement shall never exceed 100% of the maximum

amount an anesthesiologist or physician would have been allowed under the

Medical Fee Schedule Rules had the anesthesiologist or physician alone performed

these services.

(c) When an anesthesiologist is not personally administering the anesthesia but is

providing medical direction for the services of a nurse anesthetist who is not

employed by the anesthesiologist, the anesthesiologist may bill for the medical

direction. Medical direction includes the pre and post-operative evaluation of the

patient. The anesthesiologist must remain within the operating suite, including the

pre-anesthesia and post anesthesia recovery area, except in appropriately

documented extreme emergency situations. Total reimbursement for the nurse

anesthetist and the anesthesiologist shall not exceed the maximum amount

allowable under the Medical Fee Schedule Rules had the anesthesiologist

performed the services.

See Rule 0800-2-18-.05.

B. Injections

Reimbursement for injections is allowed for both the administration of the drug (the

actual injection) and the drug at Average Wholesale Price (“AWP”.) However, certain

codes include both the drug and the administration fee. In such cases, there shall be no

additional administration or injection fee. If such a code is billed for the drug, it should

be paid at 100% of Medicare. If there is no Medicare amount for the code, it can not be

paid at U&C. The drug must then be paid at AWP.

See Rule 0800-2-18-.06.

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C. Home Healthcare

These services may be paid up to a maximum of the usual and customary amount, which

is 80% of billed charges.

See Rule 0800-2-18-.02(4)(a).

D. Skilled Nursing Facility Charges

Because there is no specific amount set in the Medical Fee Schedule for these services,

the maximum allowable amount is 100% of the national Medicare amount, or usual and

customary, if no Medicare amount is listed.

See Rule 0800-2-18-.02(2)(a).

E. Outpatient Services (Including Emergency Room Care if Patient is Not

Admitted)

Payment for outpatient services is based on the Medicare model known as the Outpatient

Prospective Payment system or “OPPS.” Under the Fee Schedule, physicians are paid

separately for their professional services using the appropriate conversion factors set out

in Rule 0800-2-18-.02(4) of the Medical Fee Schedule Rules. Charges for the facility at

which the procedures are performed, such as the hospital or ambulatory surgical center

(“ASC”), are paid separately. The maximum amount for facility charges may be found in

most cases in a spreadsheet available at the Centers for Medicare and Medicaid Services’

also known as “CMS’” website, http://www.cms.hhs.gov/HospitalOutpatientPPS or at the

current CMS website which may replace this site. There are no adjustments made to this

national Medicare amount for geographic area or wage/price indices. When multiple

surgical procedures are performed during the same surgical session, maximum

reimbursement shall be based on 100% of the appropriate Medical Fee Schedule amount

for the major procedure and 50% of the lesser or secondary procedure(s); provided that

the major procedure shall be determined to be the procedure with the highest Medicare

reimbursement. Only separate and distinct surgical procedures shall be billed. The lesser

of the provider’s bill, a contracted amount, or the maximum allowable per the MFS

should be determined based on the entire bill rather than a line-by-line basis. If there is no

amount listed for the procedure performed, then the maximum that may be paid is the

usual and customary amount, which is 80% of the bill. When a bill contains both a

procedure for which Medicare lists the amount and a procedure for which there is no

Medicare amount, the unlisted procedure should be paid at 80% of the surgical charge.

The listed procedure is paid at 150% of the Medicare unadjusted amount. The lesser of

the two separate and distinct surgical procedures should be paid at 50% of the maximum

allowable, except when status indicator “S” is designated.

Technical components for radiology when done in an ASC or hospital outpatient will be

paid at 150% of Medicare, but may only be broken out when the Medicare APC code

does not include it.

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Medicare Outlier calculations are not recognized under the Tennessee Workers’

Compensation Medical Fee Schedule.

All hospitals with ambulatory patients who stay longer than 23 hours past ambulatory

surgery and are formally admitted to the hospital as an inpatient will be paid according to

the In-patient Hospital Fee Schedule Rules. All ASC’s shall be paid according to the

outpatient reimbursement formula regardless of the patient’s length of stay.

See Rule 0800-2-18-.07.

F. Laboratory/Pathology Services

The maximum allowable reimbursement for all laboratory/pathology services is 200% of

Medicare. Laboratory rates are based on Medicare’s clinical lab schedule. Hospital

(outpatient and inpatient) laboratory rates are based on 200% of the national clinical lab

schedule. Laboratory rates for non-hospital settings are based on 200% of the Tennessee

clinical lab schedule. Applicable practitioner fees, including those for pathologists and

MRO’s, are based on 200% of the TN Medicare Physician’s fee schedule based on the

conversion factor of 33.9764.

All post-injury drug screens must be paid in accordance with the Medical Fee

Schedule Rules. Drug screens not related to a workers’ compensation injury, such as

pre-employment screening, are not subject to the Fee Schedule Rules.

See Rule 0800-2-18-.02(a).

G. Radiology Services

All non-ASC, non-hospital radiology (those done in a physician’s office) may be

reimbursed up to a maximum of 200% of the Tennessee Adjusted Medicare amount for

both the technical and professional fees. This includes all Diagnostic Facilities and

Urgent Care Facilities.

See Rule 0800-2-18-.02(a).

H. Chiropractic Services

Chiropractic services are capped at 130% of the Tennessee Adjusted Medicare allowable

amount. An office visit may only be billed on the same day as a manipulation when it is

the patient’s initial visit with that provider. No charges are allowed for hot or cold packs,

nor may a fee be charged for therapeutic procedures or modalities in excess of four

combined per day. The definitions of modality and therapeutic procedure from the AMA

CPT 2005 are applicable. All physical therapy procedures performed by any chiropractor

must be pre-certified through UR just as any other physical or occupational therapy

services are under the PT/OT Rule, 0800-2-18-.09.

See Rules 0800-2-18-.08 and 0800-2-18-.09.

- 16 -

I. Physical Therapy/Occupational Therapy (PT/OT)

Reimbursement for all physical and occupational visits shall not exceed 130% of the

Tennessee Medicare allowable. Outpatient therapy performed in a hospital setting is

subject to the same reimbursement.

Precertification through the carrier’s utilization review program is not required on the

first (12) physical or occupational therapy visits. In order to facilitate expedited

utilization review, whenever a physician orders PT or OT, the physician should include

the diagnosis on the prescription for PT or OT.

Pre-certification for physical therapy of inpatients is covered under the utilization review

requirement to concurrently review inpatient admissions through discharge. Consult the

Utilization Review section of this booklet for additional information concerning these

requirements.

Functional Capacity Evaluations (“FCEs”) are reimbursable up to a maximum of usual

and customary that is, 80% of the billed charges. FCEs are NOT subject to UR and the

pre-certification requirements.

See Rule 0800-2-18-.09.

J. Speech Therapy

Speech therapy services should be reimbursed the same as physical and occupational

therapy.

See Rule 0800-2-18-.09.

K. Durable Medical Equipment and Implant Reimbursement

Durable medical equipment (“DME”) and implants for which billed charges are $100.00

or less are capped at 80% of those charges. For DME and implants over $100.00, the

maximum allowable is the manufacturers’ invoice amount plus fifteen percent (15%) of

invoice, with the 15% capped at a maximum of one thousand dollars ($1,000). This

calculation is per item and is not cumulative. The payer may request a copy of the

invoice for payment, but it is not required unless there is such a request. Implants used in

an outpatient setting are treated specially. Consult Rule 0800-2-18-.07 for specifics.

Hearing aids are considered DME if no customization is needed. However, if they are

customized, i.e., molded and fitted to the individual, then they should be considered

under this Orthotics and Prosthetics section, and reimbursed accordingly.

See Rules 0800-2-18-.07 and 0800-2-18-.10.

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L. Medical Supplies

In all cases, medical supplies and durable medical equipment (other than implants)

with applicable Medicare amounts shall be paid at the lesser of the billed charges, a

negotiated rate, or 100% of the applicable Medicare allowable amount.

See Rule 0800-2-17-.05.

M. Orthotics and Prosthetics

These devices are capped at 115% of the Tennessee Adjusted Medicare allowable

amount. If there is no Medicare amount, the maximum allowable shall be usual and

customary as defined by rule. Hearing aids are considered DME if no customization is

needed. However, if they are customized, i.e., molded and fitted to the individual, then

they should be considered under the Orthotics and Prosthetics section, and reimbursed

accordingly.

See Rule 0800-2-18-.11.

N. Pharmacy

Prescribed drugs are capped at the lesser of: the provider’s usual charge; a negotiated

contractual amount; or, the average wholesale price (“AWP”) plus a $5.10 Filling Fee

under the Fee Schedule. If the actual charge is less than this amount, then it is the

maximum allowed. Physicians dispensing drugs from their office do not receive the

additional $5.10 filling fee. All pharmaceutical bills submitted for repackaged or

compounded products must include the NDC Number of the original manufacturer

registered with the U.S. Food & Drug Administration or its authorized distributor’s stock

package used in the repackaging or compounding process. The reimbursement allowed

shall be based on the current published manufacturer’s AWP of the product or ingredient,

calculated on a per unit basis, as of the date of dispensing. A repackaged or compounded

NDC Number shall not be used and shall not be considered the original manufacturer’s

NDC Number. If the original manufacturer’s NDC Number is not provided on the bill,

then the reimbursement shall be based on the AWP of the lowest priced therapeutically

equivalent drug, calculated on a per unit basis. A compounding fee no higher than $25.00

is allowed per compound prescription if two or more prescriptive drugs require

compound preparation when sold by a hospital, pharmacy, or a provider other than a

physician.

Generally, an injured employee should receive only generic drugs or single-source

patented drugs for which there is no generic equivalent unless the authorized health care

provider writes that the brand name is medically necessary and includes on the

prescription “dispense as written” or “no substitution allowed” in the prescriber’s own

handwriting. Should an injured employee wish to receive brand name drugs when a

generic is available, she or he may do so at their own expense.

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Pharmacists may charge up to the usual and customary amount for over-the-counter non-

prescription drugs. No Filling Fee is allowed for these non-prescription drugs.

See Rule 0800-2-18-.12.

O. Ambulance Services

Pre-certification is required for all ground and air ambulance services that are non-

emergency. When it is an emergency, retro-certification is required within 72 hours of

service, or within three business days. Reimbursement for these services is capped at the

lesser of the submitted charges, or 150% of the current Medicare rate. To the extent

permitted by federal law, the rates determined in the preceding sentence shall also apply

to air ambulance services.

See Rule 0800-2-18-.13.

P. Clinical Psychological Services

Psychological treatment by any clinician other than a licensed psychiatrist is capped at

100% of the national Medicare allowable amount. Utilization review is required for all

psychological treatment services in excess of fifteen (15) visits.

See Rule 0800-2-18-.14.

Q. Surgery, Surgical Assistants and Modifiers

Physicians performing surgery may generally receive up to 200% of the allowable

Tennessee Adjusted Medicare amount. Orthopaedic and neurosurgeons may receive up

to 275% of the Tennessee Medicare amount (based on the conversion factor of 33.9764)

for surgical services only.

Multiple Procedures: Maximum reimbursement shall be based on 100% of the

appropriate Medical Fee Schedule amount for the major procedure plus 50% of the lesser

or secondary procedure(s). The major procedure shall be determined to be the procedure

with the highest Medicare reimbursement.

A physician who assists at surgery may be reimbursed up to the lesser of the surgical

assistant’s usual charge or twenty percent (20%) of the maximum allowable Medical Fee

Schedule amount. Licensed physician assistants may serve as surgical assistants but shall

be limited in reimbursement to the fee due from the procedure as calculated pursuant to

Medicare guidelines, not the conversion factors contained in the Workers’ Compensation

Medical Fee Schedule.

Modifiers should be used in a manner consistent with Medicare Guidelines and

Procedures. Modifier 22, in accordance with Medicare principles, should only be used

when a case is clearly out of the range of ordinary difficulty for that type of procedure.

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Using the example of gallbladder surgery, if a patient weighed 300 pounds and had

previous upper abdominal surgery such that adhesions in the upper abdomen were

extremely dense, the gallbladder was densely adherent to the gallbladder bed on the liver,

and the surgery time was two and one-half hours, that would be a case where the surgeon

is justified in using the -22 modifier and asking for extra reimbursement beyond the usual

Medicare fee schedule amount.

When a claim is submitted with the -22 modifier, it must be clearly evident why extra

reimbursement is being sought. There must be two separate pieces of documentation

submitted with a claim on which the -22 modifier has been appended. First, there must be

a copy of the surgeon’s operative note. The operative note must clearly document the

unusual difficulty of the case. The time that the case took should be documented in the

operative note and it is helpful if the time a usual case takes is listed for comparison.

Again, using the unusual case of gallbladder surgery above, the surgeon might report at

the end of the operative note, after describing the very difficult dissection, that the

operation took two and one-half hours, with the usual operation time being one hour and

15 minutes.

Second, there must be a separate letter from the surgeon, explaining why extra

reimbursement is being requested. Finally, these two documents should be congruent,

which is to say that the letter should not describe a terribly difficult procedure while the

operation note describes a standard case. These two separate pieces of documentation are

required because they are needed to:

• show that an unusually difficult procedure was indeed performed; and,

• allow determination of what level of extra payment above the usual Fee Schedule

amount should be allowed.

If a procedure is submitted with a -22 modifier appended to it and is allowed for

payment, but the two required pieces of documentation are not submitted with the claim,

the claim should be paid up to the normal Fee Schedule amount without any extra

allowance.

The maximum allowable additional amount under the Fee Schedule for Modifier 22

is 10% for orthopedic or neurosurgeons performing surgery at a rate up to 275% of

applicable Medicare rates.

See Rules 0800-2-18-.04 and 0800-17-.07.

Orthopaedic and neurosurgeons may use the modifier “ON” on the HCFA 1500 form,

when submitting surgical charges.

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R. Professional Services

The Centers for Medicare and Medicaid Services (“CMS”) has eliminated the use of all

inpatient and office/outpatient consultation codes for dates of service on or after January 1,

2010. Inpatient codes 99251 to 99255 and outpatient/office codes 99241 to 99245 will no

longer be accepted by CMS. As a result, medical providers who are billing under the

Tennessee Medical Fee Schedule, which is largely based on Medicare’s reimbursement

formula, will need to discontinue the use of inpatient codes 99251 to 99255 and

outpatient/office codes 99241 to 99245. Instead, medical providers should bill, as applicable:

• Initial inpatient hospital care: 99221 to 99223

• Subsequent hospital care: 99231 to 99233

• Initial nursing facility care: 99304 to 99306

• New patient office visit: 99201 to 99205

• Established patient office visit: 99211 to 99215

The official instruction issued by CMS can be found at:

http://www.cms.hhs.gov/transmittals/downloads/R1875CP.pdf

Pursuant to rule amendments that became effective on August 26, 2009, the conversion

factors below are based on the CMS’ unit conversion factor of 38.0870 which was in effect

March 2008. These conversion factors should be multiplied with the current facility/non-

facility (whichever applies) Tennessee Medicare price as determined by the type of CPT code

and date of service for dates of service through August 8, 2012.

Service Category Multiplier of

2008

Medicare

August 26-

Dec 31,

2009

Jan-May 31,

2010*

June-Dec

31, 2010

As of Jan 1,

2011**

Jan 1, 2012

–August 8,

2012 ***

CMS Conversion Factor CF=$38.0870 CF=$36.0666 CF=$36.0791 CF=$36.8729 CF=$33.9764 CF=34.0376

Chiropractic Care 130% 1.3728 1.3723 1.3428 1.4573 1.4547

General Surgery

Surgery by board

certified or board

eligible Neurosurgeon

200%

275%

2.1120

2.9041

2.1113

2.9030

2.0659

2.8405

2.2420

3.0827

2.2379

3.0772

General Medicine

(including ALL E&M)

160%

1.6896

1.6890

1.6527 1.7936 1.7903

Emergency Codes

Surgery by board

certified or board

eligible Orthopedic

surgeon

200%

275%

2.1120

2.9041

2.1113

2.9030

2.0659

2.8405

2.2420

3.0827

2.2379

3.0772

Radiology 200% 2.1120 2.1113 2.0659 2.2420 2.2379

Physical &

Occupational Therapy

130%

1.3728

1.3723

1.3428

1.4573

1.4547

Dentistry 100% 1.0560 1.0557 1.0329 1.1210 1.1190

- 21 -

* On May 10, 2010, CMS modified the conversion factor for Jan-May 2010 due to changes in

RVU amounts enacted by the Patient Protection and Affordable Health Care Act. To remain

budget neutral, CMS adjusted the conversion factor to 36.0791, which is the amount that is

applicable to the Jan-May 2010 period.

** CMS issued an emergency update to the 2011 conversion factor that was effective for all

dates of service on or after January 1, 2011.

*** CMS adjusted the 2012 conversion factor to remain budget neutral. The adjusted 2012

conversion factor is effective for dates of service from January 1, 2012 through August 8,

2012.

Pursuant to rule amendments that became effective on August 9, 2012 practitioner fees shall

be based on the conversion factor of 33.9764, which shall be used in conjunction with the

most current Medicare RVUs for all dates of service on or after August 9, 2012. The

following Tennessee specific conversion factors should be applied to the service category in

order to calculate the appropriate amount.

Service Category TN Conversion Factor

Orthopaedic and Neurosurgery* 275%

General Surgery 200%

Radiology 200%

Pathology 200%

Physical/Occupational Therapy 130%

Chiropractic 130%

General Medicine

(including evaluation & management)

160%

Emergency Care 200%

Dentistry 100%

Anesthesiology 75.00 per unit

*Orthopaedic and neurosurgeons may use the modifier “ON” on the HCFA 1500 form when

submitting surgical charges. If the modifier or another indicator is not placed on the form

then the Tennessee Department of Health’s database may be consulted in order to determine

the provider’s specialty.

- 22 -

Maximum allowable fees for professional services should always be calculated by multiplying

the current Medicare Tennessee adjusted total with the appropriate conversion factor for that

type of code and provider. The Medicare RVU’s and GPCI’s used in the following examples

are current through January 30, 2015.

Example: CPT code 99204 --- Office/outpatient visit, new patient –The maximum allowable

for Tennessee is 235.49 (160 % of TN Medicare based on the conversion factor of 33.9764).

This is calculated by the following:

(work RVU 2.43 * work GPCI 1.000) = 2.43 + (transitioned non-facility PE RVU 1.99 * PE

GPCI 0.898) = 1.787+ (MP RVU 0.22 * MP GPCI 0.524) = 0.115= 4.332

Total RVU’s = 4.332* TN conversion factor 33.9764 = 147.186* 1.6 for E&M =235.49

Example: CPT code 25444 ---Reconstruct wrist joint – The maximum allowable for

Tennessee is 1470.09 (200% of TN Medicare based on the conversion factor of 33.9764).

For orthopaedic and neurosurgeons, the maximum allowable for Tennessee is

2021.37(275% of TN Medicare based on the conversion factor of 33.9764).

This is calculated by the following:

(work RVU 11.42 * work GPCI 1.000) = 11.42 + (transitioned facility PE RVU

9.99.98* PE GPCI 0.898) =8.962+ (MP RVU 2.39* MP GPCI0.0524) =

1.252=21.634

Total RVU’s = 21.634* TN conversion factor 33.9764= 735.045* 2.0 Surgery = 1470.09

Total RVU’s = 21.634* TN conversion factor 33.9764= 735.045* 2.75 Orth/Neuro Surgeon=

2021.37

See Rule 0800-2-17-.03(14) and 0800-2-18-.02.

S. Dentistry

Dental services are capped at 100% of the Tennessee Adjusted Medicare amount. If there is

no appropriate Medicare amount (as there are not in many instances), then the maximum

amount allowed under the Medical Fee Schedule is the usual and customary amount, which is

80% of the billed charges.

See Rules 0800-2-18-.02(2)(a) and 0800-2-18-.02(4)(a).

T. Physician’s Assistants and Certified Nurse Practitioners-Maximum

Reimbursement

In accordance with a recent opinion by the Tennessee Attorney General, physician assistants

and certified nurse practitioners may provide treatment within the scope of their licensure

under the direct orders of the treating physician, and the workers’ compensation patient need

not be seen by the treating physician on each visit. Maximum reimbursement for these

practitioners is 100% of the national Medicare allowable amount based on the conversion

- 23 -

factor of 33.9764 for these types of practitioners. In no event shall reimbursement be based

on a physician’s office visit if the patient is seen only by a physician’s assistant or nurse

practitioner.

See Rule 0800-2-17-.05(4).

Except for anesthesiology, the specialty-specific multipliers listed above in Section R shall

not apply to services provided by physician assistants or nurse practitioners.

See Rule 0800-2-18-.04(2)(b).

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IV. IN-PATIENT HOSPITAL FEE SCHEDULE

The In-patient Hospital Fee Schedule, Chapter 0800-2-19, is applicable for all inpatient

hospital stays. These are defined as hospital stays which exceed 23 hours and the

employee has been formally admitted. Different rules apply for outpatient services

performed in a hospital setting. For these see Rule 0800-2-18-.07.

See Rule 0800-2-19-.02(6).

A. In-patient Hospital Services Are Reimbursed under a Per Day Methodology

In-patient services are calculated under a per day or “per diem” basis, not under the

Medicare DRG system. This is one of the areas in which the Tennessee Medical Fee

Schedule differs from the Medicare basis used throughout most of the Fee Schedule

Rules.

Reimbursement for a compensable workers’ compensation claim shall be the lesser of

the hospital’s usual charges, the PPO or other contracted amount, or the maximum

amount allowed under this In-patient Hospital Fee Schedule.

In-patient hospitals are grouped into the following separate peer groupings:

1. Peer Group 1 Hospitals

2. Peer Group 2 Rehabilitation Hospitals

3. Peer Group 3 Psychiatric Hospitals

See Rule 0800-2-18-.02(2)(b) and 0800-2-19-.01.

B. Maximum Allowable Reimbursement Amounts

The maximum per diem rates to be used in calculating the reimbursement rate is as

follows:

Surgical Admissions - $1,800.00 for the first seven (7) days; $1,500.00 per day for each

day thereafter. This includes Intensive Care (ICU) & Critical Care (CCU);

Medical Admissions - $1,500.00 for first seven (7) days; $1,250.00 per day for each day

thereafter;

Rehabilitation Hospitals - $1,000.00 for the first seven (7) days; $800.00 per day

thereafter;

Psychiatric Hospitals (applicable to chemical dependency as well) maximum allowable

amount is $700.00 per day.

- 25 -

C. Trauma care

Trauma care at any licensed Level 1 Trauma Center only shall be reimbursed at a

maximum rate of $3,000.00 per day for each day of patient stay. Actual trauma care

determines trauma rates for admissions and re-admissions. The person must have

required admission or re-admission to a trauma center and the person could not have been

treated in a non-trauma facility. Trauma must be the primary diagnosis.

Reimbursement for trauma inpatient hospital services shall be limited to the lesser of the

maximum allowable as calculated by the appropriate per diem rate, or the hospital’s

billed charges minus any non-covered charges.

A list of all trauma centers in the state may be accessed at this website:

http://www2.tennessee.gov/health/ems/TraumaCenterInspections.htm

D. Surgical implants

These shall be reimbursed separately and in addition to the per diem hospital charges

pursuant to Rule 0800-2-18-.10 of the Medical Fee Schedule Rules.

Additional reimbursement may be made in addition to the per diem for implantables (i.e.

rods, pins, plates and joint replacements, etc.). Maximum reimbursement for implantables

billed at $100.00 or less per item shall be limited to eighty percent (80%) of billed

charges. Maximum reimbursement for implantables over $100.00 is limited to the

hospital’s cost plus fifteen percent (15%) of the invoice amount, up to a maximum of

invoice plus $1,000.00 per item. This is not cumulative. Implantables shall be billed

using the appropriate HCPCS codes, when available. Billing for implantables which have

an invoice amount over $100.00 shall be accompanied by an invoice.

E. Non-covered charges

Non-covered items are: convenience items, charges for services not related to the work

injury/illness services that were not certified by the payer or their representative as

medically necessary.

F. Amounts in Addition to Per Diem Charges

The following items are not included in the per diem reimbursement to the facility and

may be reimbursed separately. All of these items must be listed with the applicable

CPT/HCPCS codes.

Durable Medical Equipment --- Items $100.00 or less, the maximum amount is 80% of

billed charges; over $100.00, the maximum amount is the manufacturer’s invoice amount

plus 15% of invoice, with the 15% capped at $1,000.00. This is NOT cumulative, but is

per item.

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Orthotics and Prosthetics --- capped at 115% of the national Medicare allowable

amount.

Implantables --- Items $100.00 or less, maximum is 80% of billed charges; over

$100.00, the maximum amount is the manufacturer’s invoice amount plus 15% of

invoice, with the 15% capped at $1,000.00. This is NOT cumulative, but is per item.

Ambulance Services --- capped at the lesser of the billed charges, or the average rate

paid for ambulance services within the same geographic area.

Take-home Medications and Medical Supplies --- Over-the-counter medications may

be reimbursed up to the usual and customary amount, 80% of billed charges. Prescription

drugs are reimbursable up to the lesser of the normal charge for the drug, or the AWP fee.

Medical Supplies shall be reimbursed pursuant to current Medicare guidelines up to

100% of the Medicare allowable amount.

Radiology Services – technical component paid per medical fee schedule according to

applicable Medicare guidelines

Lab/Pathology Services --- 200% of Medicare; Lab rates are based on 200% of

Medicare’s national clinical lab schedule.

The above-listed items are reimbursed in accordance with the Medical Cost Containment

Program Rules (Chapter 0800-2-17) and Medical Fee Schedule Rules (Chapter 0800-2-

18) payment limits. Items not listed in the Rules shall be reimbursed at the usual and

customary rate as defined in Rule 0800-2-17-.03(80), unless otherwise indicated in the

Medical Fee Schedule Rules. In-patient hospital per diem rates are all inclusive (with the

exception of those items listed above).

G. Reimbursement Calculations Explanation:

1. Each admission is assigned an appropriate DRG.

2. The applicable Standard Per Diem Amount (“SPDA”) is multiplied by the length

of stay (“LOS”) for that admission.

3. The Workers’ Compensation Reimbursement Amount (“WCRA”) is the total

amount of reimbursement to be made for that particular admission.

Reimbursement Formula: LOS X SPDA = WCRA

Example: DRG 222: Knee Procedures W/O CC

Hospital Peer Group: 1-Surgical admission:

Maximum rate per day: $1,800 first seven (7) days/$1,500 per day each day thereafter

Number billed days: 3

Billed charges (after subtracting amounts for implants, radiology, etc)…….$20,000.00

Maximum allowable payment for normal DRG stay: .. $5,400.00

Amounts due hospital for implants, radiology, etc………………………..….$4,500.00

Maximum fee schedule amount:….………………..$5,400.00 + $4,500.00 = $9,900.00

Proper reimbursement would be the lesser of billed charges, maximum fee schedule

amount, or other contracted or negotiated rate.

- 27 -

See Rule 0800-2-19-.03.

H. Stop-Loss Method

Stop-loss is an independent reimbursement factor established to ensure fair and

reasonable compensation to the hospital for unusually costly services rendered during

treatment to an injured worker.

To be eligible for stop loss payment, the total Allowed Charges for a hospital admission

must exceed the hospital maximum payment, as determined by the hospital maximum

payment rate per day, by at least $15,000. Amounts for items set forth in rule 0800-2-

19-.03(2)(d)(4) such as implantables, radiology, pathology services, DME, etc., shall

NOT be included in determining the total Allowed Charges for stop-loss

calculations.

This stop-loss threshold is established to ensure compensation for unusually extensive

services required during an admission. Once the allowed charges reach the stop-loss

threshold, reimbursement for all additional charges shall be made based on a stop-loss

payment factor of 80%. The additional charges are multiplied by the Stop-Loss

Reimbursement Factor (SLRF) and added to the maximum allowable payment.

The stop-loss formula: (Additional Charges x SLRF) + Maximum Allowable Payment =

WCRA

Example: DRG 222: Knee Procedures W/O CC

Hospital Peer Group: 1-Surgical admission:

Maximum rate per day: $1,800 first seven (7) days/$1,500 per day each day thereafter

Number billed days:…9

Billed charges (after subtracting amounts for implants, radiology, etc)…….$53,650.00

Maximum allowable payment for normal DRG stay:………………………$15,600.00

Total difference, charges over and above maximum payments……………..$38,050.00

(If this amount is $15, 000 or less, then stop loss is not applicable.)

Difference over and above $15,000 stop-loss is …………………………....$23,050.00

Payable under stop-loss (80% of $23,050.00) ……………………………...$18,440.00

Amounts due hospital for implants, radiology, etc………………………..….$3,525.00

Maximum fee schedule amount:….…..15,600.00 + 18,440.00 + 3,525.00 =$37,565.00

Proper reimbursement would be the lesser of billed charges, maximum fee schedule

amount, or other contracted or negotiated rate.

See Rule 0800-2-19-.03(4).

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I. Pre-admission Utilization Review

Payers are required to initiate utilization review for all inpatient admissions (length of

stay exceeding 23 hours) in the form of pre-admission review. If the duration of the

inpatient stay is longer than the number of days certified by pre-admission review, then

the payer shall implement concurrent review until discharge. For emergency inpatient

admissions, the payer shall begin retrospective review within one (1) business day of

notice of the admission. Review of outpatient stays is not required, but may be initiated

if a dispute regarding medical necessity exists.

The timeframes and other requirements of Chapter 0800-2-6 shall apply to all utilization

reviews of inpatient and outpatient admissions.

See Rule 0800-2-19-.04.

J. Pharmacy Services

Pharmaceutical services rendered as part of in-patient care are considered inclusive

within the In-patient Hospital Fee Schedule and shall not be reimbursed separately.

See Rule 0800-2-19-.05.

K. In-Patient Hospital Fee Schedule Definitions

In addition to the definitions set out in the Medical Cost Containment Program Rules,

Chapter 0800-2-18, there are specific definitions provided in the In-Patient Hospital Fee

Schedule Rules in Rule 0800-2-19-.02. These should be consulted to determine specific

meanings of terms used in this Schedule.

L. Penalties for Violations of the In-Patient Hospital Fee Schedule

The same rules regarding payments in excess of the Medical Fee Schedule are applicable

to this Fee Schedule.

See Rule 0800-2-19-.06.

M. Additional Information about the Medical Fee Schedule

More information on the Medical Fee Schedule is available in the Medical Fee Schedule

Rules at our website, http://www.tennessee.gov/labor-wfd/wcomp.html , at the Tennessee

secretary of state’s website, http://www.tennessee.gov/sos/rules/0800/0800-02/0800-

02.html , or through the:

Tennessee Department of Labor and Workforce Development

Division of Workers’ Compensation

220 French Landing Drive

Nashville, TN 37243

Telephone: (615) 532-1326

Electronic Mail: wc.info@tn.gov